Referral Patterns and Clinical Outcomes for Transplant-Eligible Lymphoma and Myeloma Patients Evaluated at an Urban County Hospital

Abstract

Disparities in clinical care have been described for patients with limited insurance coverage or social support. We hypothesized that patients with relapsed Hodgkin lymphoma (HL), non-Hodgkin lymphoma (NHL), or multiple myeloma (MM) treated at an urban county hospital serving indigent and under-insured patients would face barriers for referral to a private academic transplant center for autologous stem cell transplantation (ASCT). Charts of patients with HL, NHL, or MM treated at Grady Memorial Hospital between 2007 and 2013 were reviewed, and 215 patients with diagnosis of HD (n=40), NHL (n=96), and MM (n=79). 55 patients were referred for ASCT consults and 160 patients were not referred. Reasons for transplant non-referral included established clinical criteria (64% of cases), poor performance status (13%), refusal (4%), moved/lost-to-follow-up (4%), medical non-compliance (3%), death (3%), or referral to another hospital (1%). Non-referral based upon socio-economic criteria included: lack of legal immigration status/insurance (2%), and lack of social support/substance abuse (2%). Among the 55 referred patients, 27 patients (49%) underwent ASCT. Median follow-up for all referred patients from the time of diagnosis was 3.9 [0.7-22.7] years. 5-year survival from the date of diagnosis for patients who received ASCT was 80.2% versus 65.7% for non-transplanted patients (log-rank test, p-value=0.11). While the referral process did not demonstrate significant barriers based upon insurance or social status, further evaluation is needed to identify modifiable factors that can improve referral and assess the impact of the Affordable Care Act on access to ASCT.

Keywords: Autologous stem cell transplantation; Health disparity; Lymphoma; Myeloma; Referral.

Figure 1

Consort diagram for the analysis of referral 215 patients with NHL, HL, MM seen at an urban County Hospital were identified. Amongst 62 patients who were potential transplant candidates, 7 patients were not referred due to socioeconomic/ psychosocial reasons, 8 patients did not show up at the transplant center. 47 patients were seen as transplant consults.

Figure 2

Comparison of survival analysis for MM and Lymphoma patients who underwent auto-transplantation and those referred to the transplant center but not transplanted. Kaplan Meir analysis of survival from the date of diagnosis was calculated for both groups. 5 year-survival for the transplanted group (n=25) was compared to the non-transplanted group (n=20) was 80.2% vs. 65.7%, respectively (Log-rank, p=0.11).